Forget the cutting-edge diagnostic imaging and genetics, is this the future of psychiatry?

Toronto Lunatic Asylum, 1868

A new paper argues that it should be. And it’s created a fire-storm of controversy.

A journal article advocating better long-term care for patients with psychiatric illness hardly seems like the sort of essay that would spark much protest – or even interest. But if the journal is JAMA (one of the most prestigious journals in medicine) and the authors are prominent (and include a former adviser to the President and a key architect of his health legislation), then the article is likely to gather some attention.

And, of course, there is the central argument, well captured in the subtitle: “Bring Back The Asylum.”

This week’s Reading is a Viewpoint piece from JAMA, written by Dominic A. Sisti, Andrea G. Segal and Ezekiel J. Emanuel.

Find that paper here:

They begin:

During the past half century, the supply of inpatient psychiatric beds in the United States has largely vanished. In 1955, 560 000 patients were cared for in state psychiatric facilities; today there are fewer than one-tenth that number: 45 000. Given the doubling of the US population, this represents a 95% decline, bringing the per capita public psychiatric bed count to about the same as it was in 1850—14 per 100 000 people.

While Sisti et al. are writing about the U.S., the same is true across the west (as I’ve noted in an October Reading when we considered mental illness and prison populations).

The authors note that the sharp decline in beds is part of a larger “deinstitutionalization,” started in the 1960s. They note various reasons for this push away from institutional care, including better medications, federal policy, and the abuses that had occurred in asylums.

But they also suggest that deinstitutionalization is a misleading term; the proper term, they argue, is transinstitutionalization.

As state hospitals were closed, patients with chronic psychiatric diseases were moved to nursing homes or to general hospitals where they received episodic psychiatric treatment at significantly higher costs. Others became homeless, utilizing hospital emergency departments for both care and housing. Indeed, the current crisis in Nevada—where the lack of psychiatric beds has resulted in overcrowded emergency departments filled to capacity with psychiatric patients—may be a harbinger of the future. Most disturbingly, US jails and prisons have become the nation’s largest mental health care facilities. Half of all inmates have a mental illness or substance abuse disorder; 15% of state inmates are diagnosed with a psychotic disorder.

Sisti et al. note the incredible expense of this approach: incarceration costs between $30,000 and $50,000 USD a year per mentally ill prisoner.

They then recommend several alternatives:

· They advocate stronger community programs.

· They also advocate a stronger legal framework for the very ill, and champion assertive community treatment orders. They point to recent NY legislation as a model. “In New York City, after 2 years of mandated outpatient treatment, service costs for individual patients were reduced by half.” Though they also note that data on assertive community treatment orders and quality of life and well-being measures are less clear.

· And then, controversially, they argue: “Even well-designed community-based programs are often inadequate for a segment of patients who have been deinstitutionalized” – which is why they call for a return of the asylum, a “safe place” for the sickest of the sick to live.

The argument is provocative but well reasoned. Consider that community living has proven to be a failure for some patients – a noble concept but its reality is a seemingly endless series of contacts with hospital EDs, prisons, and shelters. Consider also that the legacy of asylums isn’t quite as black-and-white as it’s usually remembered. Yes, there were terrible abuses in some asylums but others offered structure and housing to those who were forgotten by society. As Dr. David Goldbloom notes in his forthcoming book, asylums were often required to be located outside of city centres, away from the dangers of urban life, offering safety. (You will note that the Toronto Lunatic Asylum was built on the then-outskirts of Toronto.)

Needless to say, the paper has sparked a response.

Writing in the New York Times, Dr. Christine Montross thinks the idea has merit.

On her hospital blog, CAMH CEO Catherine Zahn suggests asylums are best left in the past.

A google search yields many, many comments on this topic. You can read through these different essays and draw your own conclusion. But whether or not you find Sisti et al. persuasive, the problems of transinstitutionalization are very real. Consider this graph.